Let’s Escape Didactics: Virtual Escape Room as a Didactic Modality in Residency

Audience The virtual escape room is a didactic activity for emergency medicine residents (interns, junior residents, senior residents). Introduction Residency programs are employing a wide variety of active learning techniques to engage their learners, including large-group discussion, small-group activities, team-based learning, gamification, problem-based learning, role-playing and case studies. In recent years, educators have drawn their attention to educational escape rooms, a new type of learning activity that utilizes collaborative learning activities to foster creating thinking, communication, teamwork and leadership.1–3 There have been a number of cases in medicine, 4,5 but there have been limited works published on the use of virtual educational escape rooms in residency education. Unfortunately, the COVID pandemic has made participation in an escape room more difficult. In lieu of social distancing during the COVID pandemic, participation in a virtual escape room is an effective and flexible learning modality for resident didactics that appears to promote participant satisfaction, competency, learning, and engagement. Educational Objectives By the end of the activity, learners should be able to: Identify the hazardous chemicals associated with house fires Classify burn injury according to depth, extent and severity based on established standards Recall the actions to take in response to fire emergencies (R.A.C.E. and P.A.S.S. acronyms) Recall key laboratory features of cyanide and carbon monoxide poisonings Identify appropriate management strategies for smoke inhalation injuries Recite the treatment for cyanide and carbon monoxide poisonings Describe the management of the burn injuries Communicate and collaborate as a team to arrive at solutions of problems Display task-switching and leadership skills during exercise Evaluate virtual escape room experience Educational Methods Emergent care of burns, a popular and shared topic in both Emergency Medicine and Family Medicine literature, was chosen and educational objectives were developed. The website Deck.Toys was utilized to formulate the escape room along with puzzles around the educational objectives. Students congregated remotely on Zoom, and after instructions, were separated into teams to solve content-specific puzzles in order to escape the room. Teams which solve all the puzzles in the allotted time were considered to have successfully escaped the room. After the allotted time, the faculty led debriefing, and topic discussion occurred. Research Methods Sixty-three participants composed of residents (24 emergency [EM], 29 family medicine [FM], 4 combined emergency and family medicine [EM/FM]), advanced practice practitioner trainees (2 EM), and faculty member participants (4 FMP) partook in the virtual escape room experience. At the end of the activity, a 17-item survey using Likert-scale questions was embedded in order to obtain feedback regarding satisfaction, engagement, learning, and medical competency in communication, collaboration, task-switching, and leadership skills. Results Eighteen out of 63 participants filled out the survey. This was the first virtual escape room experience for 94% of the respondents. A majority (88.9%) of respondents enjoyed the virtual escape room, finding it fun, interesting, engaging, and interactive. None of the respondents preferred traditional didactics over the virtual escape room activity, and 72% were either just as or equally as satisfied with virtual compared to in-person escape rooms. Nearly all respondents agreed that the activity encouraged collaboration, communication skills, task-switching, and leadership skills (94.4%, 88.9%, 72.2%, 72.2%, respectively). Discussion Participation in a virtual escape room is an effective and flexible learning modality for resident didactics that appears to promote learner satisfaction and engagement. The escape room also promoted important competencies encouraged during residency, such as interpersonal and communication skills and practice-based learning and improvement, and is an effective addition to virtual learning tools. Topics Small group activity, team-building exercise, remote learning, virtual learning, educational games, gamification, medical education, escape room, millennials, student engagement, adult learning theory, emergency medicine residents, family medicine residents, chemicals in house fires, smoke inhalation injuries, burn classification, burn injury management, carbon monoxide poisoning, cyanide poisoning, R.A.C.E. acronym, P.A.S.S. acronym, fluid resuscitation in burn patients, burn referrals.

While the level of learners was not documented, there were sixty-three participants in total. There was a total of 57 residents (24 EM, 29 FM, 4 EMFM), 2 advanced practice practitioner trainees (EM), and 2 faculty member participants (FMP).

Time Required for Implementation:
The Deck.Toys platform will take approximately 1-5 hours prior to the session based on user experience and familiarity with the platform as well as ability to formulate puzzles and develop content. Time can be saved by accessing the premade Deck Toy template utilized in this exercise and making changes to the activities as desired (website: https://deck.toys/a/XkDiDc2IK). The actual didactic session can be tailored to 60 to 75-minute sessions depending on the learner's technical ability and familiarity with the content. Ten minutes should be allotted to activity introduction, 15-30 minutes for learners to complete the escape room depending on learner's familiarity with content, 5 minutes for a short debrief session, and 30 minutes for topic presentation and discussion.

Recommended Number of Learners per Instructor:
One instructor should be able to oversee the entire exercise, from introduction to facilitation and discussion. Since this is a team-based and learner-led activity, the instructor can rotate through each small group to answer technical questions, ensure participants are following rules, and to observe team dynamics for feedback. To alleviate the instructor duties and be more effective, one volunteer (staff, students, faculty, fellows, chief residents) for each 4 to 6member small group can be incorporated to oversee each virtual breakout room. These additional volunteers do not need background knowledge in emergency management of burn and smoke inhalation injuries. Volunteers were not utilized in our exercise, but are advised.

Topics:
Small group activity, team-building exercise, remote learning, virtual learning, educational games, gamification, medical education, escape room, millennials, student engagement, adult learning theory, emergency medicine residents, family medicine residents, chemicals in house fires, smoke inhalation injuries, burn classification, burn injury management, carbon monoxide poisoning, cyanide poisoning, R.A.C.E. acronym, P.A.S.S. acronym, fluid resuscitation in burn patients, burn referrals .

Objectives:
By the end of the activity, learners should be able to: 1.

Activity 5:
A 53-year-old male presents to hospital after suffering a burn to his hand from his stove. On examination of his skin, it appears dry, pale and has a sluggish capillary refill. Some pale areas of his burn have no significant pain. How would you classify this burn? C: Deep Partial Thickness A 5-year-old boy presents to the emergency department after burning his hand from spilled soup. He appears well. When you examine his skin, it appears erythematous with a brisk capillary refill. Three hours after his injury, you noticed that the area of erythema is starting to disappear. How would you classify this burn? A. Superficial Thickness All should be performed on a burn except: C. apply silver sulfadiazine dressings to the wound to promote healing All are acceptable medications to take/use for burn complications except: D. Flammazine

Activity 8:
What is the urine output goal in cc/hr for a 20kg child (input the answer in the lock)? 20.
Pearl #8: Fluid resuscitation in burn patients. 13 In order to determine the volume of fluid resuscitation required for a burn patient, the Rule of Nines for adults and the Lund and Browder chart for children should be utilized.
• Remember: do not include first degree burns in the calculation of % TBSA. o 2-4mL x kg body weight x % TBSA burn = volume of Lactated Ringer's required for adult resuscitation (formula adjusted to 3-4mL x kg body weight x % TBSA burn for pediatric patients). • Half of the total resuscitation volume is given over the first 8 hours, with administration of the remaining half titrated to patient response (urine output goal of 0.5mL/kg/hr for adults and 1mL/kg/hr for children). • All resuscitation measures should be guided by perfusion pressure and urine output: o Target a MAP of 60 mmHg, and urine output of 0.5-1.0ml/kg/hr for adults and 1mL/kg/h for pediatric patients.

Results and tips for successful implementation:
A total of three Virtual Escape Room sessions were held at two academic institutions during the month of April 2020, one during an emergency medicine (EM) didactic, one during family medicine (FM) didactics, and the last for a joint family medicine and emergency-family medicine (EM/FM) didactic session. Each session was led by one instructor who conducted the introductory session, small group facilitation, debriefing and content overview. There was a total of 63 participants composed of residents (24 EM, 29 FM, 4 EM/FM), advanced practice practitioner trainees (2 EM), and faculty participants (4 FMP), all of whom participated as equal team members within the group. Participants all signed into a Zoom video conferencing room, and attendance was tracked through Zoom registration so that room assignments could be randomized. The instructor randomly divided attendees into groups of four to six members during each didactic session with an attempt to assure an equal distribution of learner experience based on level of training. Four to six members was an ideal group size, allowing for small group interaction. Each group should be assigned a team lead, with the role of sharing their screen and inputting team answers into each learning activity. and screen-shared the activity for all team members to see and engage. Other team members were not provided with predetermined roles or task designations. All participants were separated into 4-to-6-member small groups via Zoom breakout rooms. The instructor entered each room periodically to answer urgent questions and observe team behaviors without directly participating in the activity or answering topic contentrelated or knowledge-based questions. Ideally, to reduce the duties of the instructor and be more effective, each team would have a faculty volunteer to perform these tasks. Question format varied from multiple choice questions that did not have to be answered correctly but informed residents of correct answers to cross-word puzzles and matching games in order to mimic the in-person escape room experience and encourage brainstorming, thinking out loud, and teamwork (see Figure 5). During the challenge in their Zoom breakout rooms, participants were allowed to use any available resources (websites, textbooks, mobile applications), other than the instructor, to answer the questions. Each team was given 15 minutes to complete the entire activity. After 15 minutes, the team that either escaped the room the fastest or progressed the farthest was announced. Although each session had at least one team complete the activity in the allotted time, a majority of teams did not complete the activity in time due to various reasons including lack of technical expertise, lack of team interaction, difficulty figuring out task puzzles, and knowledge deficits. To assure a higher completion rate, instructors can consider increasing activity completion time to 20-25 minutes or providing reading materials for pre-session preparation.
After announcing the winner of the activity, the instructor conducted a 5-minute debriefing session followed by a 30minute overview of the content covered (refer to PowerPoint attached).

Evaluation:
At the end of the activity, a 17-item survey using Likert-scale questions was embedded in order to obtain feedback regarding satisfaction, engagement, learning, and medical competency. We adapted pre-existing survey instruments to assess resident satisfaction, motivation, learning, and skills. We used items adapted from Kinio et al, Meterissian et al, and Jambhekar et al. [6][7][8] The overall response rate for the post-event survey was 18 of 63 participants (28.6%), which may have been due to the dependence of scanning the QR code or copying the survey link in order to complete the evaluation. Seventeen out of eighteen respondents had never experienced a virtual escape room. Survey and responses are available in supplemental material (Table 1).

Satisfaction
A majority (16/18 = 88.9%) of participants enjoyed the virtual escape room, with 94.4% (17 out of 18) rating the activity as fun. Five out of 18 (38.9%) rated the activity as stressful. None of the participants preferred traditional didactics over the virtual escape room activity, and 72.2% were either just as or equally as satisfied with virtual compared to in-person escape rooms.

Engagement
Engagement was high, with all categories receiving the nearly 100%. They found the challenges interesting, engaging, and interactive (94.4%).

Learning
As a learning platform, participants felt that the game was helpful in increasing (88.9%) and retaining (72.2%) clinical information. Learners either agreed or strongly agreed (88.89%) that the format helped them identify knowledge gaps. Most of the participants (94.4%) gained new knowledge while 77.8% felt that they will apply what they've learned in the future.

Competencies
Collaboration was the most encouraged skill during the activity, with 94.4% either agreeing or strongly agreeing that the activity encouraged the skill's use. Communication skills were also encouraged (88.9%). Greater than two thirds of participants agreed that it encouraged task-switching and leadership skills.